How to bypass the revolving door

Last week, I wrote about older people in nursing homes who are transferred to hospitals when their health takes a turn for the worse, even if they don’t want aggressive medical interventions. And you responded with dozens of stories about relatives who had had these experiences.

In fact, researchers who have studied the revolving door between nursing homes and hospitals think that as many as 45 percent of hospitalizations for nursing home patients (those covered by both Medicare and Medicaid) are avoidable or unnecessary.

So why do they occur? Often, nursing homes aides aren’t adequately trained to identify the early signs of deterioration in a resident’s condition and to act promptly to help prevent a medical crisis. Doctors typically aren’t present in facilities full time, and those on call often would rather be safe than sorry.

[CREDIT: Herald-Tribune archives]

Frequently, nursing home patients’ wishes — what kind of treatment they’d like to have and under what conditions — aren’t known or included in their medical records. So aggressive care is given as a matter of course.

A new pilot program in seven states that is sponsored by the federal Centers for Medicare and Medicaid Services aims to address these issues. The effort involves so-called long-stay residents (those who live in homes for 100 days or longer) in 145 nursing homes. It gets up and running later this year.

I spoke with experts from three sites – Nevada, Indiana and New York City – at length. All are trying different models but share some common elements. Notably, each program will send extra providers (nurse practitioners, registered nurses or physician assistants) into nursing homes to teach front-line staff (certified nursing assistants and others) how to better recognize and respond to changes in an older resident’s health.

“Keep in mind that these long-stay residents are very frail, with multiple chronic medical conditions that can flare up at any time,” said Dr. Greg Sachs, chief of the division of general internal medicine and geriatrics at Indiana University’s School of Medicine. “By intervening upstream, hopefully we can interrupt a cascade of medical complications that can lead to a hospitalization.”

HealthInsight of Nevada, working with 25 nursing homes, will be implementing a “green, yellow and red light” system. For each of the colors, extensive protocols – what clinical signs to watch for, how to react – have been created and will be taught to nursing home staff members. (The protocols were developed by Dr. Joseph Ouslander of Florida Atlantic University and are being used by several programs.)

Green means “something has changed but the patient is stable and it’s O.K. to keep her here,” said Dr. Jerry Reeves, HealthInsight’s medical director. An example: An older person with congestive heart failure who develops swollen ankles, a sign that her circulatory system is under stress, will get a stronger diuretic and be monitored more closely.

Yellow means the patient is unstable but “it’s still within the ability of the facility to care for Mrs. Jones,” said Dr. Reeves. This could be a patient who’s stopped eating and is now vomiting but otherwise isn’t acutely ill. Again, a medical intervention and more frequent checks will be in order.

Red signals a major change like chest pain, blood pressure that’s hard to measure or a stroke that requires immediate attention from a doctor, nurse practitioner or physician assistant. In some cases, patients will need to be transferred to the hospital; in other cases, they may remain in place at the nursing home with extra assistance.

In Indiana, the pilot will help 20 nursing homes establish nonpharmaceutical interventions for older patients with dementia. Too often, these patients are medicated with antipsychotic drugs, which puts them at risk of falls, fractures and strokes, which then land them in the hospital, Dr. Sachs said.

Other priorities will be integrating symptom-relieving palliative care more fully into the nursing home setting and better managing transfers of nursing home residents to and from hospitals when these admissions are necessary. Making sure that information about patients is transferred between settings and that medical providers communicate with one another is an important part of that.

In and around New York City, the Greater New York Hospital Foundation will be working with 30 nursing homes to ensure that older patients and their families have in-depth discussions about “goals of care” and palliative care and incorporate the substance of these discussions in medical decision-making. That involves educating caregivers about the consequences of various interventions and treatments.

“Caregivers need realistic expectations about what a hospitalization means to a person living in a nursing home,” said Roxanne Tena-Nelson, executive vice president at the foundation’s long-term care unit.

Given the enormous cultural diversity of New York and the sensitivity of the topic, “we don’t pretend this is going to be simple,” said Tim Johnson, executive director of the foundation.

Also, the New York pilot will create an “electronic dashboard” for nursing homes that eases communication among doctors and nurses, enables front-line staff to more readily identify emerging medical problems, and standardizes information that passes back and forth between nursing homes and hospitals when a patient is transferred. Most nursing homes rely on paper-based medical records currently.

The bottom line is that frail older people “should not be going to the emergency room when their care could be better delivered in another setting,” Mr. Johnson said. “We really have to take this on and make things better for this vulnerable population.”

I’m sure many readers here would second the sentiment. I’ll check back to see how these pilot programs are doing, after they have some experience under their belt.

Last modified: November 2, 2012
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